Intramedullary nailing and alternate or ancillary fixation by means of plates and pins is a well established method of treatment for fractures of the femoral diaphysis.
This method is particularly indicated in case of severely comminuted, oblique and spiral fractures as well as fractures complicated by loss of bone, and fracture of the extreme proximal and distal ends of the femoral shaft.
However the now available intramedullar nail such as the so-called KUNTSCHER or SMITH-PETERSEN nail and other fluted nails, although extremely practical in the fixation of fractures affecting the middle third of the femur, presents severe limitations when used in the treatment of the extreme proximal end, fractures of the femoral neck and intracapsular fractures.
In a paper entitled "IPSILATERAL CONCOMITANT FRACTURES OF THE HIP AND FEMORAL SHAFT" published in the June 1979 issue of The Journal of Bone and Joint Surgery (Vol 61-A No. 4), the authors recommend that whenever a fracture of the femoral shaft is diagnosed roentgenograms of the hip should be made and carefully reviewed to detect undisplaced fractures of the neck and other occult intracapsular fractures. It is further recommended that all fractures be treated by internal fixation without traction.
That same paper discloses the use of so-called KNOWLES pins combined with the proximal end of the KUNTSCHER nail for fixing fractures of the femoral shaft. This approach requires the placement of pins or screws about the perimeter of the nail. Recently developed interlocking nail techniques (such as BROOKER-WILLS and GROSS-KEMPF) do not internally stabilize peritrochanteric and intracapsular fractures.
This would require the drilling of pin holes through the proximal end of the intramedullar nail. This procedure would assume that the surgical supply room of hospitals is well stocked in nails of various lengths and pre-drilled to accept orthogonally positioned pins for the fixation of the femoral shaft as well as obliquely oriented pins along the axis of the femoral neck. In reality most hospitals stock only a limited choice of nails with no pre-drilling. This limitation in available hardware imposes some fixation compromises upon the orthopedic surgeon at one of both sides of ipsilateral fractures and reliance on less effective techniques for treatment of femoral neck and intracapsular fractures.